Healthcare Provider Details

I. General information

NPI: 1760076434
Provider Name (Legal Business Name): OTHENTIC THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2021
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16406 SW 80TH ST
MIAMI FL
33193-5713
US

IV. Provider business mailing address

16406 SW 80TH ST
MIAMI FL
33193-5713
US

V. Phone/Fax

Practice location:
  • Phone: 305-904-4124
  • Fax:
Mailing address:
  • Phone: 305-904-4124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code224ZE0001X
TaxonomyEnvironmental Modification Occupational Therapy Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: DANIELA FUNDORA
Title or Position: PRESIDENT
Credential: COTA/L
Phone: 305-904-4124